LOCAL BANKRUPTCY FORM 3015-3(b) IN THE UNITED STATES BANKRUPTCY COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA IN RE: : : : : : : CHAPTER ____ CASE NO. -bk- Debtor(s) CERTIFICATION REGARDING DOMESTIC SUPPORT OBLIGATION(S) If there are domestic support obligation claims in a case, the Bankruptcy Abuse Prevention and Consumer Protection Act of 2005 requires the trustee to provide written notice to the holder of the claim and to the applicable state child support enforcement agency. In order for the trustee to comply with the Act, the Debtor/Obligor must complete the following information and verify the information is true and correct by signing at the bottom of this form. 1. Name of Person Entitled to Receive Domestic Support ("Recipient"): Claim Holder ______________________________________________________________________ Last Name First Middle Initial 2. Address of Domestic Support Recipient: Claim Holder __________________________________________________________________ Street City __________________________________________________________________ County State Zip 3. Telephone Number of Domestic Support Recipient: Claim Holder ________________________________ (Area Code) Phone Number 4. If you are paying a Domestic Support Obligation pursuant to a Court Order, provide the following: _______________________________________________________________ Name of Court _______________________________________________________________ Address of Court _______________________________________________________________ Docket Number PACSES Number The undersigned hereby certifies that the foregoing statements are true and correct under penalty of perjury. DATED: _____________________ BY: ______________________________ Debtor American LegalNet, Inc. www.FormsWorkFlow.com